524 1997 by Excerpta Medica, Inc. 0002-9343/97/$17.00 All rights reserved. PII S0002-9343(97)00050-8 / 220e 0368 Mp 524 Thursday Jun 19 07:47 PM EL–AJM (v. 102, no. 5) 0368 Gender Differences in Patient Preferences May Underlie Differential Utilization of Elective Surgery Elizabeth W. Karlson, MD, Lawren H. Daltroy, Dr. PH, Matthew H. Liang, MD, MPH, Holley E. Eaton, RN, MA, Jeffrey N. Katz, MD, MS, Boston, Massachusetts PURPOSE: To study gender-specific preferences regarding timing of elective total joint replacement (TJR) surgery in patients with moderately severe osteoarthritis (OA) of the hip or knee. PATIENTS AND METHODS: Focus group discussions regarding TJR surgery were conducted among 18 women and among 12 men with moderately severe OA of the hip or knee. Discussions were tape recorded, transcribed, coded for themes, and evaluated semiquantitatively and qualitatively for gender differences. RESULTS: In general, men were more likely to choose surgery earlier in the disease than women and had higher expectations for surgical success. Women were more fearful of surgery. Women preferred to suffer arthritis pain rather than risk surgery, and indicated they would delay surgery to await better technology and to avoid disrupting caregiving roles for dependent spouses and others. CONCLUSION: Men and women differ in their willingness to accept continued functional decline, risks of surgery, and disruption of usual role. Gender differences may influence decisions regarding utilization of TJR. Am J Med. 1997;102:524–530.  1997 by Excerpta Medica, Inc. R ecent studies show that women tend to receive fewer costly health care interventions than men. Women with coronary artery disease are re- ferred less frequently for coronary catheterization and revascularization than men. 1–5 At the time of cardiac surgery, women have worse cardiac func- From the Department of Medicine, Division of Rheumatology and the Multipurpose Arthritis and Musculoskeletal Diseases Center (EWK, LHD, MHL, HEE, JNK); Brigham and Women’s Hospital (EWK, LHD, MHL, HEE, JNK); Harvard Medical School (EWK, LHD, MHL, JNK); and the Harvard School of Public Health (LHD), Boston, Massachusetts. Supported in part by NIH Supplement from the Office of Research on Women’s Health: AR36308, an Arthritis Foundation Postdoctoral Fellow- ship (EWK), Arthritis Foundation Investigator Award (JNK), Clinical Sci- ence Grant from the Arthritis Foundation (LHD). Requests for reprints should be addressed to Elizabeth W. Karlson, MD, 75 Francis Street, Boston, Massachusetts 02192. Manuscript submitted August 23, 1996 and accepted in revised form January 16, 1997. tional class than men and more severe disease, suggesting a delay in referral. Others have shown similar rates of procedures in men and women with severe coronary artery disease but higher rates in men with less severe disease. 6 Women are also less likely to have renal transplantation for end-stage renal disease than men, even after ad- justing for race, age, income, cause of renal failure, and type of dialysis. 7–9 Women with osteoarthritis (OA) undergoing elective orthopedic surgery have worse preoperative function than men, even after adjusting for age, comorbid conditions, and so- ciodemographic variables, 10,11 suggesting that women receive surgical treatment later in their course. Gabriel et al 11,12 also showed that women tended to have worse preoperative function but similar or less severe radiographic severity and range of motion than men. The explanation for gender differences across diverse diseases and procedures might include gender differences in the disease or its impact, biased referral, or differ- ences in risk aversiveness or patient preferences. Much of the research in this area has consisted of the descriptive epidemiology of gender differ- ences 1–5,7–13 and the question of whether proce- dures are overutilized in men. 6 The gender differ- ences in utilization remain largely unexplained. Further work in this area is especially critical in the current health care policy debate regarding high health care costs and ways to reduce overu- tilization of medical resources. We conducted focus groups of men and women with moderately severe OA of the hip or knee to generate hypotheses regarding gender differ- ences in the process of deciding on total joint re- placement. We performed qualitative analyses of the focus group discussions to uncover hypothe- ses as well as simple quantitative analysis. Our goals were: to uncover gender differences among men and women in preferences for surgery versus medical treatment for OA of the hip or knee; to determine the reasons that men and women choose total joint replacement (TJR); and to ex- amine differences between men and women in knowledge about OA and its treatment: in risk av- ersiveness, in the importance placed upon func- tional capacity, in the influence of caregiver and other responsibilities, and social support upon